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Armenia and UTMB Partnership in Primary Care 1999-2004. Jamal Islam MD MS Associate Professor Research Director Department of Family and Community Medicine TTUHSC Permian Basin. Russian Socialist Federative Soviet Republic Transcaucasian Socialist Federative Soviet Republic

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armenia and utmb partnership in primary care 1999 2004

Armenia and UTMB Partnership in Primary Care1999-2004

Jamal Islam MD MS

Associate Professor

Research Director

Department of Family and Community Medicine

TTUHSC Permian Basin

ussr before 1991 and now
Russian Socialist Federative Soviet Republic

Transcaucasian Socialist Federative Soviet Republic

Ukrainian Soviet Socialist Republic

Byelorussian Soviet Socialist Republic

Tuvan People's Republic

Kresy

Bessarabia

Finnish Karelia

Estonia

Latvia

Lithuania

Russia

Belarus

Ukraine

Moldova

Georgia

Armenia

Azerbaijan

Kazakhstan

Uzbekistan

Turkmenistan

Kyrgyzstan

Tajikistan

Estonia

Lithuania

Latvia

USSR Before 1991 and Now
armenia
ARMENIA
  • Over 4000 years as a state
  • First Christian state
  • Independence from USSR September 1991
  • Area 11,483 sq mile
  • Landlocked
  • Administrative division: 11 Region
  • Capital: Yerevan
  • Population 3.79 million (2000)

https://www.cia.gov/library/publications/the-world_factbook/geos/am.html

demographics
Demographics
  • Population 2,967,004 estimate 2009
    • Comparison
      • Azerbijan 8,041,000
      • Georgia 5,262,000
      • Turkey 66,668,000
      • USA 283,230,000

In World

  • Birth rate 12.65/1000 160th
  • Death rate 8.34/1000 100th
  • Growth rate - 0.03% 207th
  • Migration - 4.56/1000 162th
health indicators health worker
Health Indicators & Health worker

ARMENIA USA

  • Life expectancy at birth 69 (M) 76 (F) 75 (M) 81 (F)
  • Birth rate 12.6/1000 14.0/1000
  • Infant mortality 20.2/1000 6.9/1000
  • Physicians 360/100,000 416/100,000
  • Nurses 481/100,000 836/100,000
  • Health system WHO rank 104 38
  • Expenditure per capita $63 $6,096
demographics9
Demographics

M F

Median 28.8 34.4

Years %

0-14 18.2 289,119 252,150

15-64 71.1 986,764 1,123,708

65> 10.6 122,996 192,267

health problems
Health Problems
  • CVD
  • HTN
  • Smoking related lung disease
  • Maternal and child health
  • Breast Cancer
  • Respiratory disease in children
common diseases mortality per 100 000
Common DiseasesMortality (Per 100,000)

USA

(Whites)

  • CVD

Overall death 350 324

MI death 225 187

Stroke 94 44

  • Cancer death 98 187
  • MVA death 41 15
  • Intoxication 41 13
  • Infectious disease 8.5
health care system in armenia
Health Care System in Armenia
  • In 1991 dissolution of USSR placed 300 million in jeopardy for their social and health care.
  • Armenia 3.75 million people were affected

Annals of Internal Medicine 1993; 119:324-328

ussr health care system
USSR health care system

The Semashko model

  • Centrally financed through the state
  • Public owned facilities
  • State totally controls the distribution of all health resources.
  • planning, allocation of resources and managing capital
  • Expenditures through central, regional and local administrator
  • No public debate or input allowed
health care delivery system
Health Care Delivery System
  • Based around hospitals
    • Republic hospitals had 1000-2000 beds
    • Regional and district had 50-250 beds
  • Outpatient care provided by
    • Polyclinics (adjacent to hospital) 1000 visits/day
    • Village level primary care stations run by paramedics and midwife
  • OTHER
    • Military, transportation and Elite hospitals
    • Maternity hospitals at republic level and occasionally at other levels too
health care system in transition
Health care system in transition

2005 Basic Package:

  • hygiene and anti-epidemic control, primary healthcare, medical care for children, obstetrics, care for socially vulnerable groups, communicable and non-communicable disease control, and the emergency healthcare program
expansion of basic services
Expansion of basic services

2006

  • All services provided by polyclinic
  • Services not provided is paid out of pocket
    • Estimated out of pocket is 45% of service
  • State owned hospitals and Polyclinics are now semi autonomus, self-financing enterprises.
government payment
Government payment
  • Hospitals bed/day in 2006 $25.7
  • Outpatient per enrolled patients ?
  • Average Salary state owned 2006
    • General Practitioner US$ 110/month
    • Nurses US$ 87/month

J Public Health (2008) 16:183–190

american international health alliance
American International Health Alliance

“A nonprofit organization that facilitates and manages twinning

partnerships between institutions in the United States and their

counterparts overseas”

  • Targets:
    • Nation and communities with limited resources
  • Objective
    • Advance global health
    • Build institutional & human resource capacity
  • Method:
    • Peer-to-peer partnership knowledge transfer
    • Volunteer time to the project
    • Logistics provided

http://www.aiha.com/en/

funding for aiha
Funding for AIHA
  • United States Agency for International Development (USAID) Started funding in 1993
  • US Department of Health and Human Services
  • Health Resources and Services Administration (HRSA)
  • World Health Organization (WHO)
  • Global Fund to Fight AIDS, Tuberculosis and Malaria
  • German Society for Technical Cooperation (GTZ).
armenia partnerships cooperative agreement fund usaid
ARMENIA PARTNERSHIPSCooperative Agreement Fund USAID
  • 1. Yerevan/Boston, Massachusetts, 1999*
    • Boston Univ. Medical Center – training nurse and pedi emergency/trauma
  • 2. Yerevan/Los Angeles, California, 1999*
    • UCLA Medical Center – Nursing: faculty training, improve program
  • 3. Armavir/Galveston, Texas, 1999-2004. **
    • UTMB - primary care
  • 4. Gegarkunik/Providence, Rhode Island,1999-

2004**

    • Care New England – primary care

http://pdf.usaid.gov/pdf_docs/PDACG218.pdf

armenia partenerships
Armenia Partenerships
  • 5. Lori/Los Angeles, California, 1999-2004**
    • UCLA Medical Center- primary care
  • 6. Lori/Milwaukee, Wisconsin, 2003-2004
    • Center for Int. Health- Primary care training program
  • 7. Yerevan/Birmingham, Alabama, 1999-2002**
    • Univ of Alabama-post graduate training; administrators
  • 8. Yerevan/Washington, DC, 2000-2004
    • Armenian American Cultural Association and Washington Hospital Center- Breast and cervical cancer prevention
the program in numbers fiscal years 1999 2004
THE PROGRAM IN NUMBERS (Fiscal Years 1999-2004)
  • 8 = Armenia partnerships
  • 87 = US partner who traveled on exchanges to Armenia
  • 118 = Armenian partners who traveled on exchanges to US
  • 389 = Total individual exchange trips (in both directions)
  • 103,000 = Served by the 3 PHC centers established
  • $8.4 million = Total USAID funding
  • $10+ million = Value of in-kind contributions by US partners
partnership model
Partnership Model
  • Voluntarism: significant in-kind contributions of human, material, and financial resources
  • Institution-based partnering for capacity-building and systematic change
  • Peer-to-peer collaborative relationships that build mutual trust and respect
  • Transfer of knowledge, ideas, and skills through professional exchanges and mentoring
partnership model24
Partnership Model
  • Benefits flowing in both directions
  • Replication and scaling-up of successful models
  • Sustainability of achievements and relationships
  • “Partnership of partnerships” for networking, sharing, and creating common approaches and solutions
armavir and utmb partnership
Armavir and UTMB Partnership
  • Goal
    • Improve the health of individuals in the Armavir region through primary care services
armavir
ARMAVIR
  • Distance from capital: 30 miles
  • Area: 483 sq mile
  • Population 330,000
  • 3 general hospitals
  • 2 maternity hospitals
  • 11 polyclinics
  • 7 health centers
regional health care
REGIONAL HEALTH CARE
  • Armavir
    • Physician 131
    • Nurses 333
    • Field visitors 25
    • Lab assistant 14
    • Technical staff 234
  • Vagharshapat
  • Metsamor
  • Baghramyan
policlinic our base
POLICLINIC (Our Base)
  • Out patient follow-up
  • 2000/doctor
  • General practitioner 15
  • Neurologists 3
  • Ophthalmologists 2
  • Dermatologist 2
  • Surgeons 2
  • Cardiologist 2
  • Endocrinologist 1
  • Infection specialist 1
  • Psychiatrist 1
  • Gastroenterologist 1
  • Clinical/Biochemistry 3
service
Service
  • Biochemistry
  • ECG
  • Xray
  • EGD
objectives
Objectives
  • Increase training and training capacity.
  • Increase continuing education for nurses.
  • Improve record keeping.
  • Expand diagnostic laboratory capabilities in areas including management, calibration of equipment, blood safety, and infection control.
  • Encourage healthy lifestyles.
  • Expand a multidisciplinary approach to disaster preparedness
intervention
Intervention
  • Educate a core number of health professionals on screening, monitoring, using treatment guidelines, and patient education:
    • Cardiovascular disease
    • Diabetes
    • Breast cancer
    • Disaster preparedness
intervention38
Intervention
  • Medical record keeping (medical cards)
  • Standardization of laboratory and quality control
  • School teacher education on hygiene, infections, emergency preparedness, domestic violence, and smoking cessation.
performance indicator to be measured
Performance indicator to be measured
  • Establishing a learning resource center
  • Training of 56 physicians and credentialing them through the national institute of health of Armenia
  • Training 112 nurses and credentialing
  • Identify 80% of patients with diabetes, breast cancer and cardiovascular disease and monitor
  • Proportion of medical cards completed
baseline survey
Baseline Survey
  • Multistage cluster sampling
  • Hybrid self and interviewee administered
  • 1019 household
  • 3 towns 16 villages
demographics41
Demographics

(S.D)

  • Mean age years 35.6 (10.6)
  • Mean years of living in area 26.1 (13.0)
  • Mean Household member 5.3 (2)
  • Mean room 3.3 (1.2)
  • Cooking(%) Pipe Gas 35.8, Tank Gas 18.5,

Electric 36.6, Coal 4.8

  • Washing machine 44%
  • Indoor toilet 38%
  • Color TV 43%
  • Telephone 43%
  • Computer 1.5%
  • Automobile 20%
perception of health
Perception of health
  • Own health status
    • Satisfied 14.3%
    • Dissatisfied 49.8%
  • Children
    • Fair 52%
    • Poor 17.3
health utilization
Health utilization
  • 69% never sees doctor for preventive exam
  • 11.9% ever checked cholesterol
  • 12% ever screened for HTN
  • 47% female never had pap smear
  • 6.3% female ever had mammogram
depression measured 20 scale ces d
Depression Measured20 scale CES-D
  • < 17 No depression 22.3 %
  • 17- 22 Possible 22.3 %
  • > 23 Probable 55.4 %
addiction
Addiction
  • Tobacco 28.5%

male:female 22:1

  • Alcohol 14.2%
  • Drug addiction 0.3%
self reported disease
Self Reported Disease
  • Hypertension 29%
  • Vision problem 27.8%
  • Mental disorder 5.6%
  • Diabetes 3.1%
  • Cancer 0.1%
  • Accidents that required health care 26.5%
results
RESULTS:
  • Established LRC with trained person
  • Computer installed with internet connection to access information and establish email link with UTMB Galveston
results51
RESULTS
  • UTMB: Eleven physician and nine nurses completed the Train the trainers course
  • Armavir: 183 physicians, 352 nurses were trained by the trainers in several diseases: CVD, CVA, breast cancer, diabetes, personal safety, infection control, substance abuse, pediatric asthma and GI infection
results52
RESULTS
  • Increased continuing nurse education
  • Improved record keeping
  • Started Patient education on healthy life style
  • Expanded diagnostic laboratory capabilities
  • Laboratory equipment standardization, training on equipment
  • Introduced universal precaution
results54
Results
  • School teachers 15 trained on hygiene, infections, emergency preparedness, domestic violence, smoking cessation
disaster planning
Disaster Planning
  • Mock disaster training carried out
  • 150 participants were trained on the use of defibrillators, torches, and radio telephones. They also learned about EMS system in the United States
  • Galveston Hurricane preparedness administration model introduced
  • Sister city partnership with Galveston led to promise of donating surplus medical emergency equipments
success
SUCCESS?
  • Left a new concept of health care delivery
  • Creation of local capacity for “change”
  • Physicians exposed to a broader aspect of health care delivery
  • Nurses understanding and appreciation of their increased role in healthcare delivery
  • Importance of outreach services, screening and prevention
lessons learned
Lessons Learned
  • Resolving health care delivery is very complex
  • Nurse training crucial
  • Buy in from physicians essential
  • Working with administration essential
  • Do not undermine partners pride
  • Patience needed
  • Teaching institutes need to provide time and effort for helping to improve health of the world population
  • Proactive team needed in all teaching institutions for International Health
thank you
Thank you

QUESTIONS?

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